Dr. Briesacher: 00:07 Hi, this is Mark Briesacher I'm the Chief Physician Executive at Intermountain Healthcare, and I am here today with Dr. Matt Bryan, internist from the Avenues Specialty Clinic, and Dr. Anne Pendo, the Senior Medical Director for the Experience of Caring. I'm so glad that we're here today, because we're talking about a really important topic, and that is the health, and care, and well-being of people who are LGBTQ+. We recently had our Pride Festival and Pride Parade. That was a great day for a parade, beautiful and sunny. And boy, the streets were just packed.

At Intermountain Healthcare, we march in that parade. And one of the things that we shared with the community that I really loved was, some of the facts around the health of people in the LGBTQ+ community. Matt, you care for a lot of people in this community. And so, I thought maybe you could share a little bit about yourself and why understanding this from a health and mission perspective, and a health care disparities perspective, is so important.

Dr. Bryan: 01:42 Yeah, definitely. I moved here just about four years ago from Illinois after finishing residency in Chicago. I moved here for my husband's job, and I was just looking to do general primary care to any adult that needs primary care. And once I got here ... And I had an interest in LGBTQ health, but didn't expect to base my practice around that. But upon getting here, I realized there was a huge need for it. So, I kind of just fell into it via word of mouth and everything. I ended up having a very large portion of my patient population that identify as LGBTQ.

I often get asked the question, "Why do you spend so much time thinking about these patients or caring about them? Aren't they the same as us, aren't they just as equal? Aren't we all equal?" And I tend to agree wholeheartedly. Of course, we're all created equal. We all should have all the same legal rights. But one of the main issues is, especially when looking at health, there's a ton of disparities within the LGBTQ+ community. And I think it's really largely unknown to a lot of the medical providers, not just here, everywhere, that we don't even realize that a gay man has a lot stacked against him. So does a lesbian, especially transgender people. There's lots of things that providers aren't even aware are issues, so they're absolutely not being addressed. And I think it's really important to start to address them.

Dr. Briesacher: 03:23 Matt, I couldn't agree more. And I know as a pediatrician, behavioral health, depression, anxiety is such an important thing. And actually, the rates of suicide amongst youth who are LGBTQ are much higher than the general population. And so, I'm wondering if you could share what some of the health disparities are that people might be surprised to learn about.

Dr. Bryan: 03:53 Absolutely. I think that's really an important topic to bring up, especially with the youth, right? If we look at LGBTQ identified youth, they're at least two to three times more likely to attempt suicide. That's a huge number, and absolutely needs to be addressed. In general, looking beyond age-wise, there's ... In the LGBTQ community, there's higher rates of smoking-related cancers. There's higher rates of other cancers, as well. A lot of this is due to decreased frequency of screening. There is a lot that goes into that, but if you look at lesbians, for example, they're less likely to access care, therefore, they are less likely to get mammograms. They're less likely to get Pap smears, which are all indicated.

If you look at a transgender person, right, they often ... Screening is based on what anatomy a person has. If you're not paying attention to what anatomy a person has, you're not screening them appropriately. So, imagine a trans man, so someone who was assigned female at birth, who at some point transitioned, usually using testosterone, a masculinizing hormone, and they transitioned to male, so they're identified as a trans male. They would outwardly, be very masculine-appearing, right? They've got a beard. If they've had top surgery, a mastectomy, they don't have breast tissue, so they look very masculine. So, if a provider's not asking, "Do you still have a cervix? Do you still have your uterus?" you're probably not offering to do a Pap smear on that guy. And the risk of cervical cancer obviously, goes up. So, I think there's a lot of disparities there to pay attention to. And if we are not asking, we don't know.

Dr. Briesacher: 05:46 Maybe this is a question I have for both of you. What are things that a provider could do in their practice or a clinic could do, to remove some of the barriers or whatever's getting in the way of someone coming in and getting the healthcare they need, and getting the appropriate health screenings that they need?

Dr. Bryan: 06:15 I think the most important is to be as open with your patient as you can be, right, try to create a safe, welcoming environment so they feel safe in coming out to you and telling you ... These are very intimate details about your life. It's who you love, or who you are. And if you don't feel comfortable telling your provider, you're obviously not going to tell your provider. So, I think making it clear to your patients that, "This is a safe space where you can tell me anything. And if I don't know what to do, let me find a place, another safe space for you, where somebody is more knowledgeable."

But I think just being open, and being outwardly open, so that your patient knows that it's a safe place, is really important. And it can be as simple as a button, or a sign on your wall, a little rainbow sticker, a little pink triangle. There's lots of things that maybe, the vast majority of people won't even notice, but someone who's LGBTQ would hone in on that and realize, "Oh, this is a safe space." So, I think that's a perfect starting point, at least.

Dr. Pendo 07:24 The other thing I would like to add, and I've been thinking about this as I knew we were going to be coming together to talk, is, maybe a year or so after Matt joined our practice, we were having a conversation about the importance of really knowing your patient. And so, someone who looks like a John but has insurance that says Jane, and they're waiting in the waiting room, and you call them Jane, that doesn't feel good. And we had a conversation about, "How can, if our goal is to be welcoming and be a safe, trusted space to share, like you said, intimate details, what can we do as a clinic, as an office, as a team, to make it feel safe?"

And so, having some really direct, kind, open conversation with our staff, saying, "If you were in this situation, this doesn't feel good. So, what could we do to make that better?" One of the takeaways was really seeing that our caregivers, our team at Avenues, really say, "You're right, this is not okay. This is not how we want to take care of our patients, regardless. We want to make sure that this is how they feel, they feel welcome, safe, and comfortable. And so, what are we going to do differently to welcome John, even if the insurance card says Jane?"

And so, we did two things. We put "Preferred name" in the chart, so that as you pulled that up, whoever was checking our patients then, would know that. The other thing that we did is, we said, "Okay, there's got to be a bigger, broader solution, because we can't be the only office that's dealing with this." And so, "How can we partner with our Cerner folks, our Centra team, to figure out how to do that?"

Dr. Bryan: 09:41 Yeah, and so, we got the "Preferred name" placed in the center bar. So, you'll see it next to the legal name, which will be on their insurance card. Last name, first name. Right next to it, smaller font, because that's all we could accommodate, but it's still there, in parentheses is the preferred name. So, this again, reaches way more people than the piece of paper that the MA, the medical assistant, takes out to call their name. This is across, it's iCentra-wide, right, everybody can see it. What I've seen so far in our clinic is that it helps a lot. Less people have been being called the wrong name, and that's incredibly important.

Dr. Briesacher: 09:41 Yes.

Dr. Pendo 10:28 Yes.

Dr. Bryan: 10:29 Incredibly.

Dr. Briesacher: 10:30 So, Matt, I know from family and friends that there are moments as they go through life, where they don't feel welcome, and frankly and directly, they are discriminated against. And that includes healthcare. I'm wondering, what are your thoughts on that, and maybe share some experiences.

Dr. Bryan: 10:52 Yeah, yeah. I mean, I think as a primary care provider, primary care is very important. It's your first step into taking care of yourself and improving your health for now and down the road in the future. I've had countless patients come to me and tell me these really troubling stories of their struggles with a prior health care provider, right, where they've been trying to access care for something simple. Is it blood pressure, is it a rash, is it whatever? And they've been turned away, they've been mistreated. They've definitely not received the standard of care that any doctor should, or any provider should be giving to their patients.

And these stories, you think, "Oh, where are they happening? Some out, random, rural place?" Unfortunately, it's happening right here. It's right here in Salt Lake, and it's absolutely something we need to be aware of in order to create a safe space for LGBT people to come so they can start receiving their care. Because once someone gets turned away for something like that, the likelihood of them coming back to wherever they went obviously, is probably zero, let alone any other provider anywhere. They've been so harmed by that experience that they're not going to come back. And that's one of the reasons that step one, access to care, is such a disparity in this community.

Dr. Briesacher: 12:23 Just learning, and understanding, and gaining knowledge about caring for people who identify as LGBTQ is really powerful. So, first of all, congratulations and thank you for pushing that forward with our colleagues in care transformation and information systems, to get the preferred name in place. It seems like a simple thing, but I think all of us know that there rarely are simple things when it comes to that type of work. And I think even some of the things that you shared about the health disparities, a lot of people don't understand that. A lot of caregivers, a lot of physicians, and providers, advanced practice providers don't understand that. I know that we are doing some things coming up pretty soon to help everybody learn more about this, and I'm wondering if the two of you could maybe, talk a little bit about that.

Dr. Bryan: 13:27 One of the things I guess, that we are working on is to collect SOGI data.

Dr. Pendo 13:32 Can you just-

Dr. Bryan: 13:34 Of course.

Dr. Pendo 13:34 ... define that for our audience, please?

Dr. Bryan: 13:37 Of course. SOGI's an acronym, S-O-G-I, which stands for sexual orientation and gender identity. And again, creating a welcoming environment is important, but the idea is, we want to ask patients maybe, even more directly, "What is your sexual orientation," right? "Do you identify as lesbian, gay, bisexual," right? And then if we look at the gender identity side, the idea there is to identify someone who's transgender or gender-nonconforming, or non-binary. And the way we ask that is, "What sex were you assigned at birth? How do you currently identify your gender? Is it more masculine, is it more feminine, is it both, is it neither? "

And the idea is, when those don't match up, when that sex assigned at birth doesn't match the current gender identity, our goal is to have a little symbol, a little flag in the banner, that will remind people, "Hey, you know what, I should ask this patient what their pronouns are. And I need to pay attention to their preferred name, because that's going to be important, especially in this person." So, we've been working for, oh my gosh, almost a year and-a-half on collecting this data. And the idea is to pretty much at primary care visits, the patient gets handed a form where they answer these questions.

And then the medical assistant can enter it into the computer. And this is completely voluntary. Patients don't have to do it. If they feel comfortable doing it, then in a way, it's a bit easier to have that conversation with the patient about who they are. And then we can better acknowledge them and treat appropriately. So, that's, I think, step one, a big, broad step one of initially, just recognizing these folks.

After that, educational-wise, once we've identified the person, we have to know what to do with them, right? And I think that's what feedback I've heard from providers is, "Well, I don't know what to do. If a patient comes out to me and is trans, I don't know what to do with them. Or, someone comes out and they're gay, and they want to be on PREP, which is pre-exposure prophylaxis, which is HIV prevention meds." And if they have no idea what to do, they feel like a deer in headlights, and they feel like a bad provider, which is not a good feeling, as we know.

So, our next big step after this is to educate providers, right? A lot of this edu- ...0 even for me, right? I finished residency in 2015, and I didn't have a bunch of formal training on LGBTQ health. I sought it out on my own. I did external rotations in Chicago, and I learned a lot on my own, and I've done a ton of self-learning since then. So, a lot of the providers went through training before I did, and they definitely didn't have any of this training. So, just because we didn't learn it doesn't mean we don't have to know it, because it's definitely important.

So, I think one of my main goals is, we need to educate everybody that, we missed that. We need to get back on the ball. And Intermountain has been very supportive of me and others trying to educate everyone. And one of those things is PREP, right. So, like I said, the pre-exposure prophylaxis, which is actually an HIV medication, but we use it as prevention in someone who doesn't have HIV. And the USPSTF just announced this is a Grade A recommendation, which means insurance companies will be covering it soon, which is fantastic. So, patients will be asking about this, and it's something that we need to work on.

Dr. Briesacher: 17:18 And the USPTF is the United States Preventive Task Force Group that makes all sorts of recommendations on how to-

Dr. Bryan: 17:29 Exactly. And I think there's several things ... I'm going to do an Internal Medicine Grand Rounds presentation on this on July 9, I believe. So, I'll go through the whole rundown of what PREP is, and how to prescribe it, and how to feel comfortable prescribing it. So hopefully, that will make people feel more comfortable with it. I'm also working with iCentra folks to come up with a power plan, so that all of the orders are easy access right there. You don't have to remember every little detail. We are also, I'm working with iCentra as well, to get some auto text put in place, that again, make it ... You just do the auto text, and it pulls it right up for you, so you don't have to remember it all. Especially if we are learning to do this, it's going to be kind of training wheels, to get used to it. So, that's one of the next things I'm working on, is trying to make it easier for people to feel more comfortable prescribing PREP.

Dr. Pendo 18:27 So, really thinking about what's right for our patients, and then how to make it easy for the folks that are providing care to do the right thing, even if they've not received formal training in that space.

Dr. Bryan: 18:40 Exactly. And again, I hear providers say they feel like a deer in headlights when someone says, "Hey, I want PREP." And they're like, "Oh, my gosh. I don't know what that is." So here, we are just trying to make it as easy as we can to improve care for our patients.

Dr. Briesacher: 18:54 And it helps them be connected, as well. And when you can respond with confidence and knowledge, or even just acknowledge that, "I know what you're talking about. Let me look that up,"-

Dr. Bryan: 19:03 Exactly.

Dr. Briesacher: 19:03 ... that really makes a big difference. Actually, I mean, hearing the work you're doing in terms of patient services and support is really impressive. It's part of the health equality index, which is something that I'm really proud that we're working on. Because that includes not only your important work, but also looking at our policies, looking at our benefits, making sure they are inclusive, and they're nondiscriminatory, and then also investing in our community, which we have done through our sponsorship of the Pride Center, and the Pride Festival. So, I know everyone on the executive leadership team, and Mark Harrison and his leadership in this space has been inspiring, and energizing, and exciting for a lot of caregivers at Intermountain.

Dr. Pendo 20:03 I'm going to embarrass Matt now-

Dr. Briesacher: 20:05 Oh, good.

Dr. Pendo 20:05 ... because I can. One of the things that's been so, I've been so proud to watch is Matt stepping into a leadership role without a title, without authority, really, a role of influence, and saying, "This is something that's important." I mean, my patients, my practice needs it. But we have a whole community, a whole state and beyond that deserves the same care that I'm providing in my office. And taking time to say, "This is important. I'm going to own it, and I'm going to figure out how to bring a team together to work on this, to be more than one patient at a time, really, to be our whole community, is inspiring. So, I am so happy that Matt is A, in Salt Lake, and B, my partner in practice at the Avenues Specialty Clinic.

Dr. Briesacher: 21:15 Yeah, Matt.

Dr. Bryan: 21:15 Thank you. That's very sweet of you.

Dr. Briesacher: 21:17 I hope you feel really good about what you're doing. I think a lot of leaders do get started that way. And the power of taking what you know and what you've learned, and multiplying that across hundreds and hundreds of other healthcare providers and teams really is such important work. And so, thank you so much for doing that.

Dr. Bryan: 21:44 Of course, it's my pleasure. And I'm extremely happy with how I've been received. I thought I'd be barking up a tree of people who wouldn't care, or wouldn't offer support, but I've gotten tons of help from everywhere, from every step of the ladder within Intermountain. I think that speaks very highly of the organization. So, I'm not doing it alone.

Dr. Pendo 22:16 But you were the instigator.

Dr. Briesacher: 22:18 Yes.

Dr. Pendo 22:19 You were the leader. And that is so incredibly important. So, thank you.

Intermountain Healthcare is a Utah-based, not-for-profit system of 24 hospitals (includes "virtual" hospital), a Medical Group with more than 2,400 physicians and advanced practice clinicians at about 160 clinics, a health plans division called SelectHealth, and other health services. Helping people live the healthiest lives possible, Intermountain is widely recognized as a leader in clinical quality improvement and efficient healthcare delivery.